INCOME SENSITIVE REPAYMENT REQUEST
Records Code: LS200 - AASI
Version Date: 06/01/12
Federal Family Education Loan Program
To apply for an Income Sensitive Repayment Schedule for the next 12 months, complete this application and submit
documentation of your most recent total monthly gross income from all sources (i.e. pay stub). Your monthly payment
amount will be the greater of the monthly interest accrual of the loan(s) for which you are requesting an Income Sensitive
Repayment Schedule or 4% of your total monthly gross income unless you request a higher amount.
SECTION 1: BORROWER INFORMATION
Name ___________________________________________________
Account Number _________________________________
Address _________________________________________________
Telephone – Home (
) __________________________
City / State / Zip __________________________________________
Telephone – Work (
) __________________________
E-Mail Address ___________________________________________
SECTION 2: INCOME SENSITIVE PAYMENT CALCULATION
1. Monthly Gross Income:
$___________________________
Monthly Gross Income
Attach documentation of your gross monthly income from employment
and other sources.
2. Estimated Monthly Interest Accrual:
Multiply the Principal Balance of each loan by
$___________________________
Monthly Interest
the Interest Rate and then divide by 12.
3. 4% Of Income:
Multiply your Monthly Gross Income by 4% (.04).
$___________________________
4% of Income
4. Estimated Monthly Payment:
Enter the greater of lines 2 and 3.
$___________________________
Estimated Monthly Payment
5. Requested Monthly Payment:
If you would like your payment amount to be higher than the
$___________________________
Requested Monthly Payment
Amount on line 4, indicate your requested payment amount here.
SECTION 3: BORROWER AGREEMENT / ACKNOWLEDGEMENT
When we determine your payment amount based on the formula explained above, it may be necessary to increase it in order to comply with federal
regulations that require us to ensure no single installment amount in an Income Sensitive Repayment Schedule is more than three times greater than
any other installment amount.
I understand that any payments that are past due on my loan prior to the Income Sensitive Repayment Schedule will be covered by a forbearance and
any outstanding accrued interest will be added to the principal balance of my loan.
By providing a telephone number, I am expressly consenting to my schools, Department of Education, servicer, guarantor, owner, holder of my loan or
any of their respective agents or affiliates to contact me via automatic telephone dialing system or similar device and/or using a prerecorded or artificial
voice or message and/or by text message utilizing the telephone number I provide which are associated with any wireless (mobile/cellular) phone or
similar device or any other type of telephone number (including VoIP) regardless of the purpose of the communication, even if such a communication
incurs an access fee/charge from my provider/plan.
X _______________________________________
X _________________________________________
_______________
Co-Maker’s Signature (if applicable)
Borrower’s Signature
Date
Return Completed Form To:
AES
●
P.O. Box 2461
●
Harrisburg, PA 17105-2461
Fax: 717-720-3916
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